When Healthcare Met Sally
Remember the layer cake from the last post? An organization’s continued reliance on an increasingly unstable, volume-based fee-for-service foundation can materially limit its ability to succeed in non–volume-driven revenue streams such as pay-for-performance (P4P). This tension is perhaps most visible in organizations experiencing the early paradoxes of value-based success: when effective prevention and longitudinal management reduce demand for historically high-margin procedures, financial signals can appear misaligned with clinical achievement.
Experts often disagree on why value-based care stalls - whether the root cause is insufficient risk, immature data infrastructure, misaligned incentives, or cultural resistance within care delivery. Each of these explanations contains truth, but none fully account for why organizations with strong intent, capable leadership and early progress can still struggle to move forward effectively. The issue is not a lack of effort or belief; it is the difficulty of translating value-based ambition into system-level decisions organizations can actually support.
Without transparent communication around what these anticipated “signs and symptoms” of value-based success represent - and how they fit into the broader strategic context - leaders may struggle to interpret progress with confidence. Value-based care can challenge long-standing assumptions about what “good performance” looks like. Naming these shifts in advance, and preparing for them deliberately, can be prophylactic.
The instability of the cake illustration helps explain why value-based care is not exempt from W. Edwards Deming’s familiar observation: “A bad system will beat a good person every time.” Even the most capable clinicians and executives cannot reliably overcome misalignment embedded in system design. Which raises the inevitable question: if good people alone are insufficient, what does a good system for value-based care actually look like - and how does one come into being?
Some argue that deeper downside risk will resolve tensions by forcing alignment. In practice, however, increased risk without improved translation can accelerate discomfort by exposing misalignment and knowledge gaps rather than clarity in how to respond. Risk does sharpen consequences, but it does not automatically sharpen insight.
In our efforts to implement value-based care at scale, we may also miss the trees for the forest. If we are all participants in the system, then improvement at the individual level should aggregate upward. Yet value is often defined broadly and operationalized uniformly, limiting an organization’s ability to adapt care intentionally to serve individual patient needs.
Returning to the cake analogy, the limitation of a traditional layer cake is that flexibility exists only at the layer level. Even with four distinct tiers, customization is constrained to a handful of predefined combinations. What if, instead, we focused on the value delivered to individuals—rather than defaulting to a “vanilla cake with buttercream for everyone” approach?
To be clear, unlimited customization is neither practical nor desirable. Clinical variation must be bounded by evidence-based guidance, population health priorities, and operational reality. Fortunately, best-practice frameworks for preventive care and disease management already provide these guardrails. Within them, however, there remains room for meaningful personalization.
Conceptually, this begins to look less like a single cake and more like a cupcake bar. Each patient receives exactly what they need—and want—nothing more and nothing less. Each “cupcake” is constructed in alignment with individual history, social context, active diagnoses, and care plan. No two are identical, but each is intentional. The result may be less waste: fewer unused toppings, fewer inseparable cake-versus-icing tradeoffs inherent in mass production. Note that less waste does not necessarily mean less revenue - but it does require clarity about which revenue streams are intentional, sustainable, and worth defending.
Of course, it would be a wild oversimplification to suggest that healthcare operate like a cafeteria, or that such a model could be achieved perfectly in vivo. Patients’ needs evolve continuously, and the intrinsic value of human life makes the potential for moral injury unavoidable. Still, value-based care often becomes overcomplicated when it is defined abstractly and managed rigidly.
Others focus primarily on refining metrics, assuming that better measurement will naturally drive better decisions. Measurement matters. But without shared interpretation and leadership alignment, however, even precise metrics can deepen disagreement rather than resolve it.
What if we instead simplified it by defining value in explicitly patient-centered terms? Could doing so reduce unnecessary testing that burdens patients and overwhelms clinicians’ inboxes with low-yield follow-up? Is there space in our individualized culture to pause at uncertainty—or to avoid “low-value” services—when financial or emotional pressures push toward “doing everything”? These are uncomfortable questions, but they are central to the promise of value-based care.
Perhaps the path forward is not more layers, but better construction—one individual unit at a time.
If individualized value is the goal, the next question becomes unavoidable: how do we measure it—without reverting to volume in disguise? Translating patient-centered design into operational reality requires more than good intent; it demands measurement frameworks, data infrastructure, and incentives that reinforce the behaviors we claim to value. In the next post, I will explore the signs that value is under-operationalized, where measurement often goes wrong, and why many well-meaning value-based programs collapse under the weight of metrics that were never designed to serve patients—or the clinicians who care for them.
